Meadow View Health Services

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 31 residents residing in the facility.The facility did not thaw frozen food via a safe thawing method.The facility did not consistently follow safe food cooling protocol.The facility did not consistently dispose of food items in a manner that ensured food safety.Findings include:During an initial kitchen tour that began at 8:17 AM on 12/16/25, Dietary Manager (DM)-D indicated the facility follows the Food and Drug Administration (FDA) Food Code.Thawing:The 2022 FDA Food Code documents at 3-501.13 Thawing: Except as specified in (D) of this section, time/temperature control for safety food shall be thawed: (A) Under refrigeration that maintains the food temperature at 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21 degrees C (70 degrees F) or below; (2) With sufficient water velocity to agitate and float off…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not ensure the provision of foot and nail care for 8 residents (R) (R21, R5, R9, R10, R6, R27, R29, and R30) of 8 sampled residents with diabetes.The facility did not provide daily diabetic foot checks for R21, R5, R9, R10, R6, R27, R29, and R30 in accordance with professional standards of practice, the residents' care plans, and the facility's policy. Findings include:The facility's Skin Integrity-Foot Care policy, dated 12/15/23, indicates: It is the policy of the facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot .The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical condition. The facility will utilize a systematic approach for the prevention and management of foot ulcers, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure weights were monitored for 4 residents (R) (R27, R30, R36, and R37) of 12 sampled residents.The facility did not obtain weights or re-weights for R27, R30, R36, and R37 in accordance with physician orders and the facility's policy. In addition, the facility did not update the physician regarding R27, R30, R36, R37's weight loss/gain of more than 5 pounds. Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight change for our residents .6. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation .8. The threshold for significant weight change will be based on the following criteria: a. one month - 5% weight change is significant; Greater than 5% is severe. b. 3 months - 7.5% weight change is significant; Greater than 7.5% is severe. c. 6 months - 10% weight change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff and resident interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R38) of 1 sampled resident.R38 reported that $42 was taken from R38's room. The facility did not thoroughly investigate the allegation of misappropriation.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Investigation of Alleged Abuse, Neglect, and Exploitation: .Written procedures for investigations include: Providing complete and thorough documentation of the investigation .On 12/16/25, Surveyor reviewed R38's medical record. R38 had diagnoses including Prader-Willi syndrome, anxiety, and major depressive disorder. R38's Minimum Data Set (MDS) assessment, dated 9/10/25, had a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 32 of 33 residents residing in the facility. One resident received nutrition exclusively via tube feeding. The facility did not consistently label, date, and dispose of food items in a manner that ensured food safety. The facility did not consistently follow safe food cooling protocol. Findings include: On 8/27/24 at 11:50 AM, Surveyor interviewed District Manager (DM)-C who stated the facility followed the Food and Drug Administration (FDA) Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure meal items were prepared in a method that conserved the nutritive value and did not ensure menus and serving sizes were followed. This practice had the potential to affect more than 4 residents residing in the facility. One resident received nutrition exclusively via tube feeding. Kitchen staff did not follow a recipe to ensure the nutritive value was maintained during food preparation. In addition, staff did not consistently follow the menu or serving sizes. Findings include: The facility's contracted service's Menu policy, revised 9/2017, indicates: Menus will be planned in advance to meet the nutritional needs of the residents in accordance with national guidelines .Menu cycles will include standardized recipes. The facility's contracted service's Food; Quality and Palatability policy, revised 2/2023, indicates: The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R18 and R23) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R18 was transferred to the hospital on 6/14/24. Neither R18 or R18's guardian were provided with a written transfer notice. R23 was transferred to the hospital on 7/19/24. R23 was not provided with a written transfer notice. Findings include: The facility's Transfer and Discharge Policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of the resident or other individuals are endangered, or as otherwise permitted by applicable law .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R18 and R23) of 3 sampled residents reviewed for hospitalization received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R18 was transferred to the hospital on 6/14/24. Neither R18 or R18's guardian were provided with a written bed hold notice. R23 was transferred to the hospital on 7/19/24. R23 was not provided with a written bed hold notice. Findings include: The facility's Transfer and Discharge Policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of the resident or other individuals are endangered, or as otherwise permitted by applicable law .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 Residents (R) (R6 and R12) of 2 sampled residents who were reviewed for smoking. R6 was known by the facility to smoke. Staff did not accurately assess or reassess R6's ability to safely smoke. R12 was known by the facility to smoke. Staff did not complete a smoking care plan for R12. In addition, staff did not follow R12's Nicotine Assessment to ensure safe smoking. Findings include: The facility's Smoking Policy revised, 7/14/22, indicates: 1. Residents who smoke or use smokeless tobacco products shall have a Nicotine Assessment completed upon admission, quarterly, annually and PRN. 2. Risk factors identified through the assessment process shall be used in the development of the pan of care .5. If a resident is determined to be unsafe .they may be required to smoke with supervision only. 6. A resident is determined to be a hazardous smoker if he/she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility did not ensure abuse policies were implemented for 1 staff (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for background checks. The facility did not review an Integrative Background Information System (IBIS) or Department of Justice (DOJ) report prior to CNA-C's hire. Findings include: The facility's Abuse Neglect, and Exploitation policy, with a review date of 7/2022, indicated: Screening: A. Potential employees will be screened for a history of abuse, neglect, and exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees .Background checks, including rechecks, will be completed consistent with applicable state laws and regulation. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. 3. The facility will maintain documentation of proof that the screening occurred. On 7/17/23, Surveyor requested Background Information Disclosure (BID), IBIS, and DOJ…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff, resident and family interview, and record review, the facility did not develop an individualized comprehensive care plan for 1 Resident (R) (R18) of 15 sampled residents. R18's plan of care did not address R18's hearing loss. Finding include: Surveyor reviewed R18's medical record. R18 had diagnoses that included Meniere's disease left ear and depression. R18 also had a cochlear implant and an activated Power of Attorney for Healthcare (POAHC). R18's Minimum Data Set (MDS), assessment, dated 4/25/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R18 had intact cognition. The MDS also indicated R18 had the ability to hear adequately with a hearing aid and was able to be understood and understood others with a hearing aid. R18's care plan did not identify a difficulty with communication or interventions to make communication possible for R18. On 7/17/23 at 10:20 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who indicated R18's hearing aid broke and R18 needed a new one. CNA-E indicated CNA-E…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.